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l APPLICATION f ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMF64TAL HEALTH DIVISION 445 N .SAN- JOAQUIN_, ,PHONE (209)468-3420 P O`BOX 2009, 'S%CKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f f (Complete in Triplicate) Application,is hereby made to Ban Joaquin county for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health 4irvices. ob Address _� � r �,22C La�� co Lot Size/Acreage /�wnar's Name � 1-- AddressOL4 l- � <t° -?-5g� Phone Contractor �/ Address��`! License No. � Phone 11 S <S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Ll Out of service Well ❑ PUMP INSTALLATION ❑ 1 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well l3 i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation _ Dia. of Well Casing C.].DomesticlPrivata ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications �p l'1 Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout [�` _`i I'Irrigation Jf—Approx. Depth l I Eastern Surface Seal Installed by - pW '_ State Work Done , Repair an Work Done 17 � Type of Pump H.P. Sealing Material d Depth �* Well.0;struction ❑ Well Diameter V Filler Material & Depth I j Depth TYPE OF SEPTIC-WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION o septic system permitted if public sewer is t ailable within 200 feet.) Installation will serve: Residence— Commercial_,�O;her Number of living units: Number of bedrooms 'Character of soil to a depth of 3 feet:' " _ Water table depth SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin county Home owner or licensed agent's iignature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not employ any person in such manner as to become subject to workmen's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following:"l certify that in the performence of the work-for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of lifornla." The applica t ust 11 for 11 req ed i tions. Complete drawing on r verse side. �5ignad Itle: _ - - FOR DEPARTMENT USE ONLY Application Accepted by f - _ Dass=�' 3 Area 69A .5 S Pit or Grout lnspection'by_�� - lJ Data Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOU T REMITTED CKSH INFO ECEIVED BY PATE PERMIT'ND. a EH 13-24(REV.1 nal EH 14-26 J